Paper vs Computer

AdobeRN · Mar 19, 2015

Our district uses E-School - we have a section for medical documentation - office visits, screenings, immunizations etc. Check to see what your school uses for their day to day stuff maybe there is a medical section.

javgjv2012 · Mar 19, 2015

There is a section in our computer system. Currently we are writing everything on paper AND documenting it in the computer system. Which is a lot of double work! I was just wondering if other schools are going paper free and how they are making that transition.

ohiobobcat · Mar 19, 2015

We use SNAP (computer documentation) for nurse documentation. I document every student visit and all screenings in SNAP. I enter allergies, student health conditions, and I can write a narrative note under "history" for any ongoing health issues students may have. I can track immunization compliance with SNAP, too. We are looking at adding a module to SNAP that will allow us to do IHPs in SNAP for next year.

I print off an injury report for any injuries that happen at school as I need an administrator's signature for those. If a student transfers out of my district, I can print his/her entire health record from SNAP and all of that info goes with the health file. I also track my diabetic students in the computer and on paper, but that's my personal preference. It's easier for me to see blood sugar trends with my paper log. That's the only paper charting I do on a daily basis.

Do you have a way to print off info that goes into your computer if a student transfers or if you need that documentation for some reason? I am a fairly new school nurse, and at the state-run new school nurse orientation last year they told us we did not need to double document screenings in the computer AND health file.

AdobeRN · Mar 19, 2015

There is a section in our computer system. Currently we are writing everything on paper AND documenting it in the computer system. Which is a lot of double work! I was just wondering if other schools are going paper free and how they are making that transition.

Gotcha - we use computer documentation only. I will document on paper during my mass screenings - just easier and quicker for me to jot down the info on paper and enter the info later when I have time, the paper then gets shredded once entered into the computer.

Immunization info - a hard copy is kept in the students cumm folder and I will enter the info into the computer as students are enrolled. We can then run reports to follow up on those missing immunizations etc.

I do keep a paper log & document in computer my diabetics blood sugars/insulin dose/carbs - easier & quicker to be able to see the info all at once - parents like my written log better than the computer run report.

JenTheSchoolRN, BSN, RN · Mar 19, 2015

I also use SNAP. I love it and have been transitioning almost everything that was previously done on paper to SNAP. I especially like it to run reports on frequent fliers and to look at blood glucose trends for my diabetics. I also use it the med log to mark inhaler use among my asthmatics, which I have found very helpful this year. I am still learning ways for SNAP to make my job easier!

I can print all of the info out SNAP. Any screen can be printed; I automatically run off a copy of the immunization screen when another school requests a student's health records.

I still have some paper records; immunizations, physicals, medication orders, etc. I also enter that into SNAP for my convenience. The health card that get turned in at the beginning of the year I keep on file for easy access despite the fact that I do enter all the info into the computer. This card is invaluable for subs and other admins if I wasn't here for contact info. I run a copy of the card when I make an EMS call to go with the student as it has allergy info/med list/guardian contacts/insurance info/hospital of preference. There is also a box parents check that allows me to copy this card for EMS .

SnowyJ, RN · Mar 19, 2015

I have both. We have to have paper charts because we receive school physicals on paper from various MDs etc. Unless there was some sort of statewide database for health info, I fail to see how we could get around this.

Same for immunizations, med orders, etc. All on paper, but also entered into the computer.

Daily visits, i could log directly into the system, but I also keep a paper log because sometimes it's too busy to chart in real time, and I might forget some info

It's one of the things I don't like about my job..The amount of data entry I have to do. It's a pain in the butt.

SnowyJ, RN · Mar 19, 2015

And we use Infinite Campus for both academic and medical.

https://www.infinitecampus.com/

allnurses Guide · Mar 20, 2015

We have a computer system but the nurse before me didn't use it and neither do I. I write the information on the cumulative file health insert. It would be double-duty to put it in the computer.

And you all know how much I hate electronic medical records.

There is a recent thread from a physician who wrote about a seizure patient who is a child. On his blog, there is another piece about electronic medical records. Thought I'd share it here.

Please Choose One Â« Philip Allen Green MD

MollyJ · Mar 20, 2015

And you all know how much I hate electronic medical records.

Perhaps we can form a support group. I'm using ours under duress. No one would ever think that ours was put together in consultation with nurses but many nurses obviously think the computer is the future and they embrace it uncritically. That last part is the part I don't understand.

NutmeggeRN, BSN · Mar 24, 2015

Same for immunizations, med orders, etc. All on paper, but also entered into the computer.
Daily visits, i could log directly into the system, but I also keep a paper log because sometimes it's too busy to chart in real time, and I might forget some info
It's one of the things I don't like about my job..The amount of data entry I have to do. It's a pain in the butt.

When our regionally affiliated school sends their freshmen, I have to enter every single Iz by hand, dose by dose, date by date (the same with new registrations) :sniff: ......It is a pain as we are on different systems....the upside is, I get paid time in the summer to do it. :yes: